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The maternal organism reacts to a greater or lesser extent under the influence of pregnancy, but naturally the most characteristic changes are observed in the generative tract, and especially the uterus, which undergoes a very marked increase in size.

—J. Whitridge Williams (1903)

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INTRODUCTION

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In the first edition of this textbook, Williams devoted only 10 pages to the physiology of pregnancy, and half were focused on uterine growth. Many gestational changes begin soon after fertilization and continue throughout pregnancy. Equally astounding is that the woman is returned almost completely to her prepregnancy state after delivery and lactation. Most pregnancy-related changes are prompted by stimuli provided by the fetus and placenta. Virtually every organ system undergoes alterations, and these can appreciably modify criteria for disease diagnosis and treatment. Thus, an understanding of pregnancy adaptations is essential to avoid misinterpretation. Moreover, some physiological changes can unmask or worsen preexisting disease.

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REPRODUCTIVE TRACT

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Uterus

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In the nonpregnant woman, the uterus weighs approximately 70 g and is almost solid, except for a cavity of 10 mL or less. During pregnancy, the uterus is transformed into a thin-walled muscular organ of sufficient capacity to accommodate the fetus, placenta, and amnionic fluid. The total volume of the contents at term averages 5 L but may be 20 L or more! Thus, by the end of pregnancy, the uterus has achieved a capacity that is 500 to 1000 times greater than the nonpregnant state. The corresponding increase in uterine weight is such that, by term, the organ weighs nearly 1100 g.

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During pregnancy, uterine enlargement involves stretching and marked hypertrophy of muscle cells, whereas the production of new myocytes is limited. Fibrous tissue also accumulates, particularly in the external muscle layer, together with a considerable rise in elastic tissue content. The walls of the corpus considerably thicken and strengthen during the first few months of pregnancy but then gradually thin. By term, the myometrium is only 1 to 2 cm thick, and the fetus usually can be palpated through the soft, readily indentable uterine walls.

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Uterine hypertrophy early in pregnancy probably is stimulated by the action of estrogen and perhaps progesterone. Thus, similar uterine changes can be observed with ectopic pregnancy. But after approximately 12 weeks’ gestation, uterine growth is related predominantly to pressure exerted by the expanding products of conception.

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Within the uterus, enlargement is most marked in the fundus. The extent of uterine hypertrophy is also influenced by the position of the placenta. Namely, the myometrium surrounding the placental site grows more rapidly than does the rest.

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Myocyte Arrangement
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The uterine musculature during pregnancy is arranged in three strata. The first is an outer hoodlike layer, which arches over the fundus and extends into the various ligaments. The middle layer is a dense network of muscle fibers perforated in ...

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